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Fabris-Moraes W, Lacerda GJM, Pacheco-Barrios K, Fregni F. The Impact of Obesity as a Peripheral Disruptor of Brain Inhibitory Mechanisms in Fibromyalgia: A Cross-Sectional Study. J Clin Med 2024; 13:3878. [PMID: 38999444 PMCID: PMC11242580 DOI: 10.3390/jcm13133878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 06/28/2024] [Accepted: 06/29/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objective: Obesity, characterized by chronic inflammation, may serve as a surrogate marker for more dysfunctional peripheral inflammation, potentially exacerbating FM symptomatology. Given this premise, this study aimed to investigate the effects of obesity as an effect modifier on neural and clinical variables, specifically those indexing pain-compensatory mechanisms in FM symptoms. Methods: A cross-sectional study was conducted with 108 participants who underwent a standardized TMS protocol assessment to measure resting motor threshold (MT), intracortical facilitation (ICF), and intracortical inhibition (ICI). Clinical data were collected using Beck's Depression Index (BDI), PROMIS, the Brief Pain Inventory (BPI), and conditioned pain modulation (CPM). Linear regression models were used to explore the relationship between these variables while examining Body Mass Index (BMI) as a potential effect modifier. If it was found to be a modifier, we stratified the sample into two groups with a BMI cutoff of 30 and performed another regression model within the subgroups. Results: BMI was identified as an effect modifier in the relationships between ICI and BDI, PROMIS fatigue, and CPM and in MT versus CPM. After stratification, non-obese fibromyalgia subjects demonstrated significant correlations between clinical symptoms and CPM and ICI activity. However, these correlations were absent in the obese group, suggesting obesity disrupts pain mechanisms and their compensatory effects. Higher MT values were associated with weaker endogenous pain control, particularly evident in the obese group. Conclusions: Obesity appears to be a significant effect modifier and delineates two patient groups across multiple clinical and neural assessments of fibromyalgia. Additionally, it suggests a role for obesity in exacerbating fibromyalgia symptoms and disrupting physiological pain-inhibitory mechanisms.
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Affiliation(s)
- Walter Fabris-Moraes
- Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA 02129, USA; (W.F.-M.)
- Faculty of Medicine FMUSP, University of São Paulo, São Paulo 01246-903, SP, Brazil
| | - Guilherme J. M. Lacerda
- Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA 02129, USA; (W.F.-M.)
- Faculty of Medicine FMUSP, University of São Paulo, São Paulo 01246-903, SP, Brazil
- Instituto de MedicinaFísica e Reabilitação, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo 04116-030, SP, Brazil
| | - Kevin Pacheco-Barrios
- Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA 02129, USA; (W.F.-M.)
- Unidad de Investigación para la Generación y Síntesis de Evidenciasen Salud, Vicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima 150114, Peru
| | - Felipe Fregni
- Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA 02129, USA; (W.F.-M.)
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Caumo W, Lopes Ramos R, Vicuña Serrano P, da Silveira Alves CF, Medeiros L, Ramalho L, Tomeddi R, Bruck S, Boher L, Sanches PRS, Silva DP, Ls Torres I, Fregni F. Efficacy of Home-Based Transcranial Direct Current Stimulation Over the Primary Motor Cortex and Dorsolateral Prefrontal Cortex in the Disability Due to Pain in Fibromyalgia: A Factorial Sham-Randomized Clinical Study. THE JOURNAL OF PAIN 2024; 25:376-392. [PMID: 37689323 DOI: 10.1016/j.jpain.2023.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/07/2023] [Accepted: 09/01/2023] [Indexed: 09/11/2023]
Abstract
This randomized, double-blind, controlled clinical trial compared the effectiveness of home-based-(HB) active transcranial direct current stimulation (a-tDCS) over the left dorsolateral prefrontal cortex (l-DLPFC) or primary motor cortex (M1) with their respective sham-(s)-tDCS to determine whether a-tDCS would be more effective than s-tDCS in reducing pain and improving disability due to pain. The study included 102 patients with fibromyalgia aged 30 to 65 years old randomly assigned to 1 of 4 tDCS groups using a ratio of 2:1:2:1. The groups included l-DLPFC (a-tDCS, n = 34) and (s-tDCS, n = 17), or tDCS on the M1 (a-tDCS, n = 34) or (s-tDCS, n = 17). Patients self-administered 20 sessions of tDCS, with 2 mA for 20 minutes each day under remote supervision after in-person training. The Mixed Model for Repeated Measurements revealed that a-tDCS on DLPFC significantly reduced pain scores by 36.53% compared to 25.79% in s-tDCS. From baseline to the fourth week of treatment, a-tDCS on M1 reduced pain scores by 45.89% compared to 22.92% over s-tDCS. A generalized linear model showed a significant improvement in the disability scale in the groups that received a-tDCS compared to s-tDCS over M1 20.54% versus 2.49% (χ2 = 11.06, df = 1, P < .001]), while on DLPFC the improvement was 14.29% and 5.77%, with a borderline significance (χ2 = 3.19, df = 1, P = .06]), respectively. A higher reduction in serum brain-derived neurotrophic factor from baseline to treatment end was positively correlated with decreased pain scores regardless of the treatment group. The application of a-tDCS over M1 increased the heat pain threshold and the function of the descending pain inhibitory system. PERSPECTIVE: These findings provide important insights: (1) HB-tDCS has effectively reduced pain scores and improved disability due to fibromyalgia. (2) The study provides evidence that HB-a-tDCS is a viable and effective therapeutic approach. (3) HB-a-tDCS over M1 improved the function of the descending pain inhibitory system and increased the heat pain threshold. Finally, our findings also emphasize that brain-derived neurotrophic factor, as an index of neuroplasticity, may serve as a valuable marker associated with changes in clinical pain measures. TRIAL REGISTRATION: Number NCT03843203.
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Affiliation(s)
- Wolnei Caumo
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil; Laboratory of Pain and Neuromodulation at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil; Pain and Palliative Care Service at HCPA, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil; Department of Surgery, School of Medicine, Porto Alegre, Rio Grande do Sul, Brazil
| | - Rael Lopes Ramos
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Paul Vicuña Serrano
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Camila Fernanda da Silveira Alves
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil; Laboratory of Pain and Neuromodulation at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
| | - Liciane Medeiros
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil; Pain Pharmacology and Neuromodulation Laboratory, Preclinical Investigations, Experimental Research Center, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil; Postgraduate Program in Health and Human Development, La Salle University, Canoas, Rio Grande do Sul, Brazil
| | - Leticia Ramalho
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Rafalea Tomeddi
- Laboratory of Pain and Neuromodulation at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
| | - Samara Bruck
- Laboratory of Pain and Neuromodulation at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
| | - Lucas Boher
- Laboratory of Pain and Neuromodulation at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil; Pain and Palliative Care Service at HCPA, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil; Department of Surgery, School of Medicine, Porto Alegre, Rio Grande do Sul, Brazil
| | - Paulo R S Sanches
- Laboratory of Biomedical Engineer at HCPA, Porto Alegre, Rio Grande do Sul, Brazil
| | - Danton P Silva
- Laboratory of Biomedical Engineer at HCPA, Porto Alegre, Rio Grande do Sul, Brazil
| | - Iraci Ls Torres
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil; Pain Pharmacology and Neuromodulation Laboratory, Preclinical Investigations, Experimental Research Center, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
| | - Felipe Fregni
- Laboratory of Neuromodulation and Center for Clinical Research Learning, Physics and Rehabilitation Department, Spaulding Rehabilitation Hospital, Boston, Massachusetts
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Cuenca-Martínez F, Sempere-Rubio N, Mollà-Casanova S, Muñoz-Gómez E, Fernández-Carnero J, Sánchez-Sabater A, Suso-Martí L. Effects of Repetitive-Transcranial Magnetic Stimulation (rTMS) in Fibromyalgia Syndrome: An Umbrella and Mapping Review. Brain Sci 2023; 13:1059. [PMID: 37508991 PMCID: PMC10377383 DOI: 10.3390/brainsci13071059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/05/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The main aim of this study was to assess the effects of repetitive-transcranial magnetic stimulation (rTMS) in patients with fibromyalgia (FMS). METHODS We systematically searched PubMed, PEDro, EMBASE, and CINAHL. Methodological quality was analyzed using the AMSTAR and ROBIS scales, and the strength of evidence was established according to the guidelines advisory committee grading criteria. A total of 11 systematic reviews were included. The assessed variables were pain intensity, depressive symptoms, anxiety, and general health. RESULTS Regarding pain intensity, it seems that high-frequency rTMS significantly reduces pain intensity at a 1-month follow-up when the primary motor cortex (M1) is stimulated. However, we cannot robustly conclude the same for low-frequency protocols. When we look at the combination of high and low-frequency rTMS, there seems to be a significant effect on pain intensity up to 1-week post-intervention, but after that point of follow-up, the results are controversial. Regarding depressive symptoms and anxiety, results showed that the effects of rTMS are almost non-existent. Finally, in regard to general health, results showed that rTMS caused significant post-intervention effects in a robust way. However, the results of the follow-ups are contradictory. CONCLUSIONS The results obtained showed that high-frequency rTMS applied on the M1 showed some effect on the variable of pain intensity with a limited quality of evidence. Overall, rTMS was shown to be effective in improving general health with moderate quality of evidence. Finally, rTMS was not shown to be effective in managing depressive symptoms and anxiety with a limited to moderate quality of evidence. PROSPERO number: This review was previously registered in PROSPERO (CRD42023391032).
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Affiliation(s)
| | | | | | - Elena Muñoz-Gómez
- Department of Physiotherapy, University of Valencia, 46010 Valencia, Spain
| | - Josué Fernández-Carnero
- Department of Physical and Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28922 Madrid, Spain
- La Paz Hospital Institute for Health Research, IdiPAZ, 28922 Madrid, Spain
- Grupo de Investigación en Neurociencia Cognitiva, Dolor y Rehabilitación en Ciencias de la Salud (NECODOR), Universidad Rey Juan Carlos, 28922 Madrid, Spain
| | | | - Luis Suso-Martí
- Department of Physiotherapy, University of Valencia, 46010 Valencia, Spain
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Stankewitz A, Mayr A, Irving S, Witkovsky V, Schulz E. Pain and the emotional brain: pain-related cortical processes are better reflected by affective evaluation than by cognitive evaluation. Sci Rep 2023; 13:8273. [PMID: 37217563 DOI: 10.1038/s41598-023-35294-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023] Open
Abstract
The experience of pain has been dissociated into two interwoven aspects: a sensory-discriminative aspect and an affective-motivational aspect. We aimed to explore which of the pain descriptors is more deeply rooted in the human brain. Participants were asked to evaluate applied cold pain. The majority of the trials showed distinct ratings: some were rated higher for unpleasantness and others for intensity. We compared the relationship between functional data recorded from 7 T MRI with unpleasantness and intensity ratings and revealed a stronger relationship between cortical data and unpleasantness ratings. The present study underlines the importance of the emotional-affective aspects of pain-related cortical processes in the brain. The findings corroborate previous studies showing a higher sensitivity to pain unpleasantness compared to ratings of pain intensity. For the processing of pain in healthy subjects, this effect may reflect the more direct and intuitive evaluation of emotional aspects of the pain system, which is to prevent harm and to preserve the physical integrity of the body.
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Affiliation(s)
- Anne Stankewitz
- Department of Neuroradiology, Klinikum Rechts Der Isar, Technische Universität München, Munich, Germany
| | - Astrid Mayr
- Department of Radiology, University Hospital, Ludwig-Maximilians-Universität München, A: Marchioninistr. 15, 81377, München, Germany
| | - Stephanie Irving
- Department of Neurology, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Viktor Witkovsky
- Department of Theoretical Methods, Institute of Measurement Science, Slovak Academy of Sciences, Bratislava, Slovak Republic
| | - Enrico Schulz
- Department of Radiology, University Hospital, Ludwig-Maximilians-Universität München, A: Marchioninistr. 15, 81377, München, Germany.
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
- Department of Medical Psychology, Ludwig-Maximilians-Universität München, Munich, Germany.
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Pimenta DC, Lima D, Slawka E, Pacheco-Barrios K, Fregni F. Editorial: Bench to Bedside - the translation of intracortical inhibition marker to clinical practice. PRINCIPLES AND PRACTICE OF CLINICAL RESEARCH (2015) 2022; 8:92-97. [PMID: 37449292 PMCID: PMC10343941 DOI: 10.21801/ppcrj.2022.83.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Affiliation(s)
- Danielle Carolina Pimenta
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Daniel Lima
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Eric Slawka
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Kevin Pacheco-Barrios
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Felipe Fregni
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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Functional connectivity response to acute pain assessed by fNIRS is associated with BDNF genotype in fibromyalgia: an exploratory study. Sci Rep 2022; 12:18831. [PMID: 36336706 PMCID: PMC9637689 DOI: 10.1038/s41598-022-23476-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/01/2022] [Indexed: 11/07/2022] Open
Abstract
Fibromyalgia is a heterogenous primary pain syndrome whose severity has been associated with descending pain modulatory system (DPMS) function and functional connectivity (FC) between pain processing areas. The brain-derived neurotrophic factor (BDNF) Val66Met single nucleotide polymorphism has been linked to vulnerability to chronic pain. In this cross-sectional imaging genetics study, we investigated fibromyalgia, the relationship between BDNF Val66Met heterozygous genotypes (Val/Met), and the functional connectivity (FC) response pattern to acute pain stimulus in the motor (MC) and prefrontal (PFC) cortex assessed by near-infrared spectroscopy (fNIRS) before and after a cold pressor test utilizing water (0-1 °C). Also, we assessed the relationship between this genotype with the DPMS function and quality of life. We included 42 women (Val/Val = 30; Val/Met = 12) with fibromyalgia, ages 18-65. The MANCOVA comparing Val/Met to Val/Val genotypes showed higher ΔFC between left(l)-PFC-l-MC (β = 0.357, p = 0.048), l-PFC-right(r)-PFC (β = 0.249, p = 0.012), l-PFC-r-MC (β = 0.226, p = 0.022), and l-MC-r-PFC (β = 0.260, p = 0.016). Val/Met genotypes showed higher efficiency of the DPMS and lower disability due to pain. Here we show that fibromyalgia patients carrying the Val/Met BDNF genotype presented an increased ΔFC across MC and PFC in response to acute pain associated with differences in acute pain perception and fibromyalgia symptoms.
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Pacheco-Barrios K, Lima D, Pimenta D, Slawka E, Navarro-Flores A, Parente J, Rebello-Sanchez I, Cardenas-Rojas A, Gonzalez-Mego P, Castelo-Branco L, Fregni F. Motor cortex inhibition as a fibromyalgia biomarker: a meta-analysis of transcranial magnetic stimulation studies. BRAIN NETWORK AND MODULATION 2022; 1:88-101. [PMID: 35845034 PMCID: PMC9282159 DOI: 10.4103/2773-2398.348254] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Fibromyalgia (FM) is a common and refractory chronic pain condition with multiple clinical phenotypes. The current diagnosis is based on a syndrome identification which can be subjective and lead to under or over-diagnosis. Therefore, there is a need for objective biomarkers for diagnosis, phenotyping, and prognosis (treatment response and follow-up) in fibromyalgia. Potential biomarkers are measures of cortical excitability indexed by transcranial magnetic stimulation (TMS). However, no systematic analysis of current evidence has been performed to assess the role of TMS metrics as a fibromyalgia biomarker. Therefore, this study aims to evaluate evidence on corticospinal and intracortical motor excitability in fibromyalgia subjects and to assess the prognostic role of TMS metrics as response biomarkers in FM. We conducted systematic searches on PubMed/Medline, Embase, and Cochrane Central databases for observational studies and randomized controlled trials on fibromyalgia subjects that used TMS as an assessment. Three reviewers independently selected and extracted the data. Then, a random-effects model meta-analysis was performed to compare fibromyalgia and healthy controls in observational studies. Also, to compare active versus sham treatments, in randomized controlled trials. Correlations between changes in TMS metrics and clinical improvement were explored. The quality and evidence certainty were assessed following standardized approaches. We included 15 studies (696 participants, 474 FM subjects). The main findings were: (1) fibromyalgia subjects present less intracortical inhibition (mean difference (MD) = -0.40, 95% confidence interval (CI) -0.69 to -0.11) and higher resting motor thresholds (MD = 6.90 μV, 95% CI 4.16 to 9.63 μV) when compared to controls; (2) interventions such as exercise, pregabalin, and non-invasive brain stimulation increased intracortical inhibition (MD = 0.19, 95% CI 0.10 to 0.29) and cortical silent period (MD = 14.92 ms, 95% CI 4.86 to 24.98 ms), when compared to placebo or sham stimulation; (3) changes on intracortical excitability are correlated with clinical improvements - higher inhibition moderately correlates with less pain, depression, and pain catastrophizing; lower facilitation moderately correlates with less fatigue. Measures of intracortical inhibition and facilitation indexed by TMS are potential diagnostic and treatment response biomarkers for fibromyalgia subjects. The disruption in the intracortical inhibitory system in fibromyalgia also provides additional evidence that fibromyalgia has some neurophysiological characteristics of neuropathic pain. Treatments inducing an engagement of sensorimotor systems (e.g., exercise, motor imagery, and non-invasive brain stimulation) could restore the cortical inhibitory tonus in FM and induce clinical improvement.
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Affiliation(s)
- Kevin Pacheco-Barrios
- Neuromodulation Center and Center for Clinical Research
Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital,
Harvard Medical School, Boston, MA, USA
- Universidad San Ignacio de Loyola, Vicerrectorado de
Investigación, Unidad de Investigación para la Generación y
Síntesis de Evidencias en Salud, Lima, Peru
| | - Daniel Lima
- Neuromodulation Center and Center for Clinical Research
Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital,
Harvard Medical School, Boston, MA, USA
| | - Danielle Pimenta
- Neuromodulation Center and Center for Clinical Research
Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital,
Harvard Medical School, Boston, MA, USA
| | - Eric Slawka
- Neuromodulation Center and Center for Clinical Research
Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital,
Harvard Medical School, Boston, MA, USA
| | - Alba Navarro-Flores
- Georg-August-University Goettingen, International Max
Planck Research School for Neurosciences, Goettingen, Germany
| | - Joao Parente
- Neuromodulation Center and Center for Clinical Research
Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital,
Harvard Medical School, Boston, MA, USA
| | - Ingrid Rebello-Sanchez
- Neuromodulation Center and Center for Clinical Research
Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital,
Harvard Medical School, Boston, MA, USA
| | - Alejandra Cardenas-Rojas
- Neuromodulation Center and Center for Clinical Research
Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital,
Harvard Medical School, Boston, MA, USA
| | - Paola Gonzalez-Mego
- Neuromodulation Center and Center for Clinical Research
Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital,
Harvard Medical School, Boston, MA, USA
| | - Luis Castelo-Branco
- Neuromodulation Center and Center for Clinical Research
Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital,
Harvard Medical School, Boston, MA, USA
| | - Felipe Fregni
- Neuromodulation Center and Center for Clinical Research
Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital,
Harvard Medical School, Boston, MA, USA
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